OTHER SERVICES
Inaccessible Waiver Services - TC
Pg. 161-162 of 333, “This service shall provide expertise, training, and technical assistance in any of the following specialty areas to assist family members, caregivers, and other service providers in supporting the individual. Therapeutic consultation may not include direct therapy provided to waiver individuals other than Behavioral Consultation. Therapeutic consultation services may not duplicate the activities of other services available to the individual through the State Plan. In particular, the case manager must first access consultation from physical therapists, occupational therapists, speech and language therapists through the State Plan when State Plan services are available to an individual. Virginia attests that no duplication of therapeutic consultation in the waiver and EPSDT services will be permitted and will ensure that each child has access to all services to which he/she is entitled through EPSDT.”
The requirement for, “the case manager must first access consultation from physical therapists, occupational therapists, speech and language therapists through the State Plan” is a barrier to accessing this waiver service, which is not a medical service, and only provides, “expertise, training, and technical assistance”; not direct therapy. Yet, the individual has to have medical necessity for direct therapy; the provider has to be licensed to provide direct therapy; and the authorization process that would require waiver providers to enroll in MCOs to provide direct therapy is identical to that of direct therapy. If all these conditions exist, then the individual can get their needs met by medical services under the state plan.
Like all HCBS waiver services, access to TC should not require meeting a higher level of medical necessity than the HCBS waiver service provides. Remove the requirement to first access consultation from the State Plan.
Assistive Tech Criteria Omission
Pg. 90 of 333, “enable individuals to increase their abilities to perform activities of daily living (ADLs), or to perceive, control, or communicate with the environment in which they live, or which are necessary for life support, including the ancillary supplies and equipment necessary to the proper functioning of such technology.”
These criteria omit the current criteria, “actively participate in other waiver services that are part of their plan for supports,“ which many individuals and waiver service providers have relied on to improve utilization of services that increase access to their community, independent living skills, direct their services, and achieve a variety of outcomes.
Please add this important criteria back into the waiver AT service.
Disparity for Children with Disabilities - EPSDT AT
Pg. 90 of 333, “In accordance with the CMS Informational Bulletin issued on July 7, 2014, assistive technology for individuals under age 21 shall be accessed through the state plan pursuant to EPSDT. Assistive technology through this waiver shall not be available to individuals under age 21.”
The EPSDT criteria are stricter than the waiver AT service criteria, creating an inherent disparity in access to AT for disabled children compared to equivalently disabled adults. Children requesting AT to enable their abilities to participate in ADLs, to perceive, control, or communicate with their environment, or to actively participate in other waiver services that are part of their plan for supports are denied if the AT item does not alleviate the effects of, or maintain their diagnosis from worsening, while adults with the same disability and the same requested AT item would be approved. Most personal care and hygiene items that enable the individual to autonomously clean themselves or feed themselves are only accessible to those waiver recipients 21 years old or older because they do not meet the EPSDT criteria.
Please allow children with an HCBS waiver to access the waiver AT service, which they are eligible to receive, and funds have been allocated to, if their request does not meet the stricter EPSDT AT criteria.
Appendix C: Participant Services, C-1/C-3: Service Specification, Assistive Technology, Service Definition, 2nd paragraph, page 90
Needed assistive technology has been denied by DBHDS working from a narrow definition of assistive technology. DBHDS has justified their denials of requested assistive technology by determining the needed items are not medically necessary. The definition in the draft Application (for remedial or direct medical benefit) will perpetuate these narrow and harmful determinations. Congress reauthorized the AT Act in December, 2022 of the reauthorization in 2004 to update and modernize AT for people with disabilities. DMAS should follow federal trends towards the future, instead of further limiting the opportunities of people with disabilities to access services and to interact with a modern society. The draft application for this HCBS service is nearly identical to the State Plan criteria for medical equipment, with waiver recipients are already eligible to receive.
RECOMMENDATION: Expand the definition to include the clearer assistive technology core service definition on page 177 of the Centers for Medicare and Medicaid Services (CMS), “Instructions, Technical Guide and Review Criteria” for 1915(c) waivers. The CMS definition focuses on functional abilities, not only medical needs. Medical benefit should remain a part of the definition as well.
Appendix C: Participant Services, C-1/C-3: Service Specification, Employment and Community Transportation, Service Definition, page 126
Activities of the Employment and Community Transportation provider are primarily administrative.
RECOMMENDATION: Permit required administering agency activities to be provided via telehealth.
Appendix C: Participant Services, C-1/C-3: Service Specification, Employment and Community Transportation, Service Definition, page 126
The draft Application requires verification that the individual “does not have sufficient personal funds financial resources” to pay for the transportation themselves. Other Medicaid services do not require such verification of ability to pay. Requiring this verification is not time well spent by providers, especially considering the rate structure for administering agencies.
RECOMMENDATION: Remove requirements for verification of the ability for the individual to pay for transportation.
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Employment and Community Transportation, Provider Qualifications, page 127
Centers for Independent Living are not licensed by DBHDS. Centers for Independent Living incorporated in the Commonwealth of Virginia must meet the requirements in Virginia Code, § 51.5-161.
RECOMMENDATION: Modify the Provider Qualifications item by listing Centers for Independent Living in the Other Standard block.
Appendix C: Participant Services, C-1/C-3: Service Specification, Environmental Modifications, Service Definition, page 130
Individuals who are trying to transition from nursing facilities and other institutions may need the residence they previously lived in or a new residence to be accessible before they can transition. Experiences have included people leaving the institution by stretcher, the transportation company lifting the individual up home stairs, and then the individual having no way to leave their home, if a needed ramp was not installed prior to their transition home. This could be the situation if the individual did not use a wheelchair before going into the institutional setting or if they leave an institutional setting to a home different from where they lived before their institutionalization. CMS allows the needed environmental modification to be authorized and begun while the individual is still in the institution. This allowance is described on page 174 of the CMS, “Instructions, Technical Guide and Review Criteria” for 1915(c) waivers.
RECOMMENDATION: Allow authorization of environmental modifications needed for transition from an institutional setting up to 180 days in advance of transition from an institutional setting.
Appendix C: Participant Services, C-1/C-3: Service Specification, Environmental Modifications, Service Definition, page 130
Environmental modifications needed to repair a modification are sometimes denied if Medicaid did not initially fund the item needing repair. For example, if an individual had a lift installed on a van with the individual’s funds and subsequently the lift needs repair outside of warranty or routine maintenance, the repair or maintenance is denied due to the lift being purchased by the individual instead of with Medicaid funds. Other examples include needed repairs for a home accessibility ramp when the individual financed the ramp and the ramp needing repair or maintenance.
RECOMMENDATION: Include in the definition that repairs and necessary maintenance to environmental modifications are allowable services, regardless of the funding source of the initial environmental modification.
Appendix C: Participant Services, C-1/C-3: Service Specification, Environmental Modifications, limits on the amount, frequency or duration of this service, 3rd paragraph, page 130
This standard can result in a ramp being built in a location that blocks ease of access by other family members, that is uncovered resulting in the individual being exposed unnecessarily to the weather, or built on a path of travel that is not lit at night. The existing limit of $5,000 for environmental modifications is already a significant restriction to people receiving environmental modifications that are ideal for safety and independent use by the individual. The determination about how the modification should be designed and installed should be made by professionals with architectural, design and/or safety backgrounds and not constrained by an offsite analyst without this background.
RECOMMENDATION: Eliminate language that can restrict the provision of environmental modifications to a lesser modification than what has been recommended due to a cost effectiveness standard (least expensive manner possible) that minimizes the use of the modification.
Appendix C: Participant Services, C-1/C-3: Service Specification, Peer Mentor Supports, limits on the amount, frequency or duration of this service, 2nd paragraph, page 141
An unreasonable stipulation in the draft Application would require “all other available and appropriate funding sources must be explored and exhausted.” This standard does not apply to other FIS Waiver services. This is a requirement that cannot be reasonably assured, possibly resulting a reluctance for individuals and case managers to pursue this service.
RECOMMENDATION: Remove the sentence: “Prior to accessing funding for this waiver service, all other available and appropriate funding sources must be explored and exhausted.”
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Peer Mentor Administrating Agency, Provider Qualifications, page 142
DBHDS does not license Centers for Independent Living. Centers for Independent Living incorporated in the Commonwealth of Virginia must meet the requirements in Virginia Code, § 51.5-161.
RECOMMENDATION: List Centers for Independent Living in the Other Standard block.